• Student first name:
• Student last name:
• Birthdate: (example: mm/dd/yyyy)
• Age:
• Grade:
• Gender: [Male Female ]
• State student ID:
• OSPI Case #:
• School:
• District: Anacortes Arlington Bellingham Blaine Burlington-Edison Concrete Conway Coupeville Darrington Edmonds Everett Ferndale Granite Falls Index La Conner Lake Washington Lake Stevens Lakewood Lopez Island Lynden Marysville Meridian Monroe Mount Baker Mount Vernon Mukilteo Nooksack Valley Northshore Oak Harbor Orcas Island Riverview San Juan Island Seattle Sedro-Woolley Shaw Island Shoreline Snohomish South Whidbey Stanwood-Camano Sultan
• Teacher:
• District liaison:
• Student's home address:
• Street number:
• City:
• State:
• Zip code:
• Student lives with:
• Legal relationship:

• Please provide the name and best phone numbers for the parents or guardians.
• Name:
• Phone #1:
• Phone #2:
• Name:
• Phone #1:
• Phone #2:
• Emergency Contact
• Name:
• Phone:
• Physician Name:
• Physician Phone:
• Physician Address:

• Parent's primary language, if other than English:
• Parent interpreter needed:
• Student's primary language, if other than English:
• Student interpreter needed:
• ASL: SEE: PSE: Other:

• Is this student in Special Education? [Yes No ]
• Is this student covered under 504? [Yes No ]
• Date of most recent IEP: (example: mm/dd/yyyy)
• Date of most recent Evaluation Summary: (example: mm/dd/yyyy)
• Current status, check any that apply:
• Drop out: Expelled: Parole: Probation: BECCA:
• Other:
• Probation Officer
• Name:
• Phone:

• Identified disability area(s):
• Check if applicable (required for Discoveries and Regional Learning Centers):
• FBA: [Yes No ] Date: (example: mm/dd/yyyy)
• BIP: [Yes No ] Date: (example: mm/dd/yyyy)

Referred program:

• Northwest Regional Learning Center (NRLC)
• Snohomish Discovery
• Whatcom Discovery

• Describe your school district's senior project requirement:
• Contact person regarding senior project:
• Description of current regular (mainstreamed) and special education program:
• Reason for requesting placement with cooperative program:
• Interventions attempted:
• Community relationships and resources,
  i.e. peers, law enforcement, DCFS, mental health, other:

• Does student take routine/daily medication? [Yes No ]
• If Yes, please list each medication, proper dosage, and possible side effects.
• Medical condition:

To complete the application process, the following materials must be completed and forwarded to the program Site Administrator:

• Signed parental release to share confidential information with the program staff
• Current Evaluation Summary
• Current IEP
• Current Functional Behavior Assessment and Behavior Improvement Plan
• Teacher's Report Form, if applicable
• Relevant medical/mental health records
• Current Immunization records
• Description of current adjustment difficulties and interventions attempted
• Student Transcripts

Upon receipt of these items, the administrator will review referral information in order to expedite this request.

• Application was completed by:
• Name:
• Title:
• E-mail:

Please review the form. The highlighted fields are required. Please update the form and resubmit.

Please send your printed materials to the addresses listed below. Thank you.